A decade-long analysis of gender, race, and ethnic representation of incoming cardiothoracic anesthesiology fellows.

PURPOSE OF REVIEW: This study calls attention to the necessity for increasing representation of minority groups among cardiothoracic fellowship programs. RECENT FINDINGS: Demographics in medicine are changing, with more women and varying ethnicities contributing to the physician pool. Despite this change, diversity among cardiothoracic anesthesia fellows has not mirrored this trend. SUMMARY: In November of 2022, medical student, anesthesia resident and cardiothoracic fellow demographics were analyzed from 2011 to 2021 to assess the changes in program diversity. Although male and female individuals have relatively similar representation in medical schools, female individuals only represent 34.8% of total US anesthesia residents. Cardiothoracic anesthesia fellowship programs continue to be male-sex dominant and white racial representation has consistently made up a majority of the total trainees. Increasing diversity amongst healthcare providers increases the likelihood of providing culturally competent care, thereby decreasing the healthcare gap in minority communities.

Resident Physicians as Clinical Educators in Anesthesiology: A Narrative Review.

The importance of resident physicians as clinical educators is widely acknowledged in many clinical specialties and by national accreditation organizations for medical education. Within anesthesiology training programs, there is growing attention to the role of trainees as clinical educators. This narrative review describes the theoretical and demonstrated benefits of clinical teaching by residents in anesthesiology and other medical fields, summarizes current efforts to support and promote residents as educators, and suggests ways in which anesthesiology training programs can further assess and develop the role of residents as clinical educators.

A modern roadmap for the use of simulation in regional anesthesiology training.

PURPOSE OF REVIEW: A variety of educational modalities are used to teach regional anesthesia. Simulation is an educational tool that facilitates hands-on learning in a well tolerated, reproducible environment, eliminating potential harm to patients during the process of learning. Available literature and expert consensus statements support customizing simulation programs according to the level of training and experience of the learners. RECENT FINDINGS: Simulation is useful for learners of all levels of expertise, though the application and frequency of simulation must be adapted to meet the learners' objectives. SUMMARY: This review presents recommendations for the use of simulation for residents, fellows, practicing anesthesiologists without formal training in regional anesthesia, and practicing anesthesiologists with regional anesthesia expertise. Passports and portfolio programs that include simulation can be used to verify training. Virtual applications of simulation are growing, expanding the scope of regional anesthesia simulation and increasing access to lower resource areas.

The Anesthesiology Milestones 2.0: An Improved Competency-Based Assessment for Residency Training.

The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation's residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME's current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.

Con: The Length of Adult Cardiothoracic Anesthesiology Fellowship Training Should Not Be Extended Beyond One Year.

Fellowship training in adult cardiothoracic anesthesiology (ACTA) is a one-year postgraduate experience with formal accreditation by the Accreditation Council for Graduate Medical Education. ACTA is a competitive and evolving subspeciality. With expanding knowledge, clinical roles and technical skills required of the modern cardiothoracic anesthesiologists, the optimal structure and duration of the fellowship training are worth considering. This manuscript provides supporting rationale for fellowship training in ACTA to remain one year in duration. The expanding responsibilities of the cardiothoracic anesthesiologist and strategies to best train the future of the subspecialty within the current training structure are discussed. It also briefly examines the history and current status of the fellowship training, reviews considerations for increasing fellowship duration, and highlights personal and financial considerations during the training.

Development of an Objective Structured Clinical Examination as a Component of Assessment for Initial Board Certification in Anesthesiology.

With its first administration of an Objective Structured Clinical Examination (OSCE) in 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate this type of assessment into its high-stakes certification examination system. The fundamental rationale for the ABA's introduction of the OSCE is to include an assessment that allows candidates for board certification to demonstrate what they actually "do" in domains relevant to clinical practice. Inherent in this rationale is that the OSCE will capture competencies not well assessed in the current written and oral examinations-competencies that will allow the ABA to judge whether a candidate meets the standards expected for board certification more properly. This special article describes the ABA's journey from initial conceptualization through first administration of the OSCE, including the format of the OSCE, the process for scenario development, the standardized patient program that supports OSCE administration, examiner training, scoring, and future assessment of reliability, validity, and impact of the OSCE. This information will be beneficial to both those involved in the initial certification process, such as residency graduate candidates and program directors, and others contemplating the use of high-stakes summative OSCE assessments.

[Analysis of the personnel development in anesthesiology over the last two decades with special attention to gender aspects]. / Eine Analyse der Personalentwicklung in der Anästhesiologie unter besonderer Berücksichtigung von Gender-Aspekten.

Skills shortage of nursing staff and physicians is a "hot topic" in health politics. For the future recruitment of medical staff in anesthesiology, an analysis of the staff development during the last decades considering gender aspects seems to be important. Therefore, the authors conducted a comparative analysis of data from the "Statistisches Bundesamt" (Fachserie 12 Reihe 7.3.1 and Fachserie 12 Reihe 6.1.1.) from 1994 until 2015. The analysis compared the development of anesthesiological staff (physicians) with the overall development of medical staff (physicians) in respect of the number of residents, consultants and department chairs. There are two major differences between the development of medical staff in anesthesiology and the overall development of medical staff: (1) in anesthesiology there is a high percentage of consultants without management tasks, (2) though the percentage of female colleagues is increasing both in anesthesiology and overall, the percentage of female colleagues in management or chair positions is lower in anesthesiology compared to the other disciplines, altogether. Anesthesiology is a discipline in which both the number of tasks and personnel have risen over the last two decades. The comparatively huge increase in the number of residents and consultants without management tasks suggests that the number of tasks in daily routine has substantially increased for anesthesiologists. The comparatively low percentage of female colleagues in chair positions should give an impulse to improve the compatibility of family and working live both for clinical and scientific careers.

Anesthesia Development in Mongolia: Strengthening Anesthesia Practice in Mongolia Through Education and Continuing Professional Development.

Anesthesia in Mongolia has undergone a period of major development over the past 17 years, thanks to the work of the Mongolian Society of Anesthesiologists (MSA) and the support of the World Federation of Societies of Anaesthesiologists and the Australian Society of Anaesthetists. The specialty has made major advances in training and in its standing among medical specialties in Mongolia. The MSA has produced members who are leaders in the development of anesthesia as well as emergency medicine and critical care. This has been achieved by engagement between the Ministry of Health and MSA, and with inexpensive but efficient programs to educate trainees and provide continuing professional development. There is now major work being done to achieve the Lancet Commission on Global Surgery goals of safe and accessible surgery for the population in a country that faces significant challenges of remote communities with vast distances.

Education: The Heart of the Matter.

There are inadequate numbers of anesthesia providers in many parts of the world. Good quality educational programs are needed to increase provider numbers, train leaders and teachers, and increase knowledge and skills. In some countries, considerable external support may be required to develop self-sustaining programs. There are some key themes related to educational programs in low- and middle-income countries:(1) Programs must be appropriate for the local environment-there is no "one-size-fits-all" program. In some countries, nonuniversity programs may be appropriate for training providers.(2) It is essential to train local teachers-a number of short courses provide teacher training. Overseas attachments may also play an important role in developing leadership and teaching capacity.(3) Interactive teaching techniques, such as small-group discussions and simulation, have been incorporated into many educational programs. Computer learning and videoconferencing offer additional educational possibilities.(4) Subspecialty education in areas such as obstetric anesthesia, pediatric anesthesia, and pain management are needed to develop leadership and increase capacity in subspecialty areas of practice. Examples include short subspecialty courses and clinical fellowships.(5) Collaboration and coordination are vital. Anesthesiologists need to work with ministries of health and other organizations to develop plans that are matched to need. External organizations can play an important role.(6) Excellent education is required at all levels. Training guidelines could help to standardize and improve training. Resources should be available for research, as well as monitoring and evaluation of educational programs.

Are Short Subspecialty Courses the Educational Answer?

There is an urgent need to train more anesthesia providers in low- and middle-income countries (LMICs). There is also a need to provide more educational opportunities in subspecialty areas of anesthetic practice such as trauma management, pain management, obstetric anesthesia, and pediatric anesthesia. Together, these subspecialty areas make up a large proportion of the clinical workload in LMICs. In these countries, the quality of education may be variable, there may be few teachers, and opportunities for continued learning and mentorship are rare. Short subspecialty courses such as Primary Trauma Care, Essential Pain Management, Safer Anaesthesia From Education-Obstetric Anaesthesia, and Safer Anaesthesia From Education-Paediatric Anaesthesia have been developed to help fill this need. They have the potential for immediate impact by providing an opportunity for continuing professional development and relevant subspecialty training. These courses are all short (1-3 days), are presented as an off-the-shelf package, and include a teach-the-teacher component. They use a variety of interactive teaching techniques and are designed to be adaptable and responsive to local needs. There is an emphasis on local ownership of the educational process that helps to promote sustainability. After an initial financial outlay to purchase equipment, the costs are relatively low. Short subspecialty courses appear to be part of the educational answer in LMICs, but there is a need for research to validate their role.

[Reform of emergency physician training in Austria : Finally up to date?] / Reform der Notarztausbildung in Österreich : Endlich zeitgemäß?

During the last 20 years Austrian prehospital emergency medical services (EMS) have significantly improved. The structure and organization of Austrian EMS comply with European standards but training requirements for prehospital EMS physicians are insufficient when compared with other countries. Although some EMS systems follow the German or Swiss postgraduate training concepts, the legal requirements in Austria defining the scope of mandatory training for physicians in the prehospital setting are only minimal. Thus, besides board certification as a general practitioner or specialist of any discipline, the only formal requirement is a 1-week theoretical course comprising some manikin simulations. Experience in anesthesia or intensive care medicine is still not mandatory. The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) drafted a reform paper in 2009, which was adapted by the Austrian Chamber of Physicians, section of emergency medicine, and subsequently presented to the Austrian Ministry of Health. Due to the slowness of the legislation process, the relevant § 40 of the Austrian Physician 's Act is still unchanged. In the meantime, Austrian specialist training regulations were restructured in 2015 with significant consequences. Due to changes in the residency programs, board certification and subsequent full working permit becomes more difficult to obtain, thus further aggravating the shortage of emergency physicians in Austria. In order to counteract the threatening shortage of prehospital EMS physicians, the ÖGARI section of emergency medicine was requested by the Ministry of Health to develop a reasonable model for how physicians could be qualified and subsequently employed in EMS prior to full board certification. Presently, the Austrian Ministry of Health, the Chamber of Physicians and medical societies are in discussion on whether this approach might fit into the legal framework. This manuscript details the development and present status as well as key points of an ongoing discussion on how high-quality EMS care in Austria can be safeguarded in the future or could even make it impossible.

Making robust assessments of specialist trainees' workplace performance.

BACKGROUND: Workplace-based assessments should provide a reliable measure of trainee performance, but have met with mixed success. We proposed that using an entrustability scale, where supervisors scored trainees on the level of supervision required for the case would improve the utility of compulsory mini-clinical evaluation exercise (CEX) assessments in a large anaesthesia training program. METHODS: We analysed mini-CEX scores from all Australian and New Zealand College of Anaesthetists trainees submitted to an online database over a 12-month period. Supervisors' scores were adjusted for the expected supervision requirement for the case for trainees at different stages of training. We used generalisability theory to determine score reliability. RESULTS: 7808 assessments were available for analysis. Supervision requirements decreased significantly (P < 0.05) with increased duration and level of training, supporting validity. We found moderate reliability (G > 0.7) with a feasible number of assessments. Adjusting scores against the expected supervision requirement considerably improved reliability, with G > 0.8 achieved with only nine assessments. Three per cent of trainees generated average mini-CEX scores below the expected standard. CONCLUSIONS: Using an entrustment scoring system, where supervisors score trainees on the level of supervision required, mini-CEX scores demonstrated moderate reliability within a feasible number of assessments, and evidence of validity. When scores were adjusted against an expected standard, underperforming trainees could be identified, and reliability much improved. Taken together with other evidence on trainee ability, the mini-CEX is of sufficient reliability for inclusion in high stakes decisions on trainee progression towards independent specialist practice.

To err is human: use of simulation to enhance training and patient safety in anaesthesia.

Human beings who work in complex, dynamic, and stressful situations make mistakes. This is as true for anaesthetists as for any other health-care professional, but we face unique challenges in the many roles and responsibilities we have in diverse clinical contexts. As a profession, we are well versed in the development and utilization of improvement techniques and technologies that prioritize high-quality, safe care for patients. This article focuses on one particular domain of patient safety in which anaesthetists have been pre-eminent, the use of simulation in training to improve both professional capabilities and patient safety in anaesthetic practice. This review considers the impact of error in health care; the role of anaesthetists in promoting simulation-based education for the development of clinical skills and improved teamwork; and their role in disseminating human factors and quality improvement science to enhance safety in the clinical workplace. Finally, we consider our position at the vanguard of developments in patient safety and how the profession should continue to pursue a leadership role in the application of simulation-based interventions to training and systems design across health care.

Preparing anesthesiology faculty for competency-based medical education.

PURPOSE: Competency-based medical education (CBME) is quickly becoming the dominant organizing principle for medical residency programs. As CBME requires changes in the way medical education is delivered, faculty will need to acquire new skills in teaching and assessment in order to navigate the transition. In this paper, we examine the evidence supporting best practices in faculty development, propose strategies for faculty development for CBME-based residency programs, and discuss the results of faculty development initiatives at the pioneering anesthesia CBME residency program at the University of Ottawa. SOURCE: Review of the current literature and information from the University of Ottawa anesthesia residency program. PRINCIPAL FINDINGS: Faculty development is critical to the success of CBME programs. Attention must be paid to the competence of faculty to teach and assess all of the CanMEDS roles. At the University of Ottawa, some faculty development initiatives were very successful, while others were hindered by factors both internal and external to the residency program. Many faculty development activities had low attendance rates. CONCLUSIONS: Faculty development must be considered in the rollout of any new educational initiative. Experts suggest that faculty development for CBME should incorporate educational activities using multiple teaching and delivery methods, and should be offered longitudinally through the planning, development, and implementation phases of curriculum change. Additionally, these educational activities must continue until all faculty have demonstrated an acceptable level of competence. Faculty buy-in is paramount to the successful delivery of any faculty development program that is not mandatory in nature.

[A Trained-in-Japan Anesthesiologist Going Through Anesthesia Training in the United States : What Adjustments Should be Made for Upcoming Renewal in Anesthesia Board Certification in Japan?].

We reviewed the anesthesiology training in the United States from the viewpoint of Japanese Anes- thesiologists. The Accreditation Council for Graduate Medical Education (ACGME) strictly supervises anes- thesiology residency programs in the U.S. Recently, the ACGME has become stricter on training supervi- sion, and American Board of Anesthesiology (ABA) revised its board examination system. The quality of anesthesia training in the U. S., how- ever, is decreasing because of new regulations. Addi- tionally, in the continuing economic recession, hospitals have started to hire more nurse anesthetists (CRNA) with cheaper salary than anesthesiologists. This situa- tion led more anesthesiology residents to seek an extra year of subspecialty fellowship training and research experience. This trend will come to Japan in the near future, for which we should be well prepared. As the first step, the process for Japanese Anesthesiology Board Recertification should be modified. Continuing medical education should be mandatory for each re- newal with recertification examination. Second, the number of residents and the quality of each program should be strictly supervised by a third party. Lastly, we should encourage residents to seek subspecialty training and more research experience to become bet- ter anesthesiologists.

A case for competency-based anaesthesiology training with entrustable professional activities: an agenda for development and research.

Competency frameworks are based on what are considered to be the general essential qualities of a doctor. Competencies, being behavioural descriptors, need a strong link to clinical practice to allow trainers to observe and then use them in assessing trainees' performance. The emerging concept of entrustable professional activities (EPAs) may serve as such a link. An EPA is a description of an essential clinical task that frames competencies in the context of clinical practice. A full set of EPAs defines a specialty and constitutes the curriculum of specialty training. After observation of satisfactory performance on an EPA, the resident should be permitted to perform that activity without direct supervision. The terms of this should allow a trainer to provide justification for this decision. This makes graded assumption of responsibilities possible. We describe the potential benefits of working with EPAs in anaesthesiology training and set an agenda for curriculum development and research in this area.

Adapting Simulation Curricula to the Future Needs of Anesthesiology.

We have discussed some examples of the types of program development strategies that are in common use and have presented examples of the type of performance gaps that can occur when a coordinated curriculum development process is not applied (or is applied in an uncoordinated fashion). We have outlined one method to develop a simulation-based curriculum focusing more on ways to identify how to "simulate what is needed" rather than using the "simulate what we know" style. We believe that curricula must be designed to continually evolve rather being conceived as a single finished program. We have attempted to illustrate what a designed simulation curriculum for training anesthesiology residents and faculty in the PSH might look like, and we have provided a sample scenario to illustrate how this process could be presented (Supplemental Digital Content 2, http://links.lww.com/AIA/A23, Supplemental Digital Content 3, http://links.lww.com/AIA/A24). Our hope is that this model may be applied to create simulation education curricula in a wide variety of areas. We suggest that it be a part of any attempt to create a standardized, longitudinal simulation-based assessment for residents or practitioners. A cohesive, strategic approach to simulation curriculum design and implementation will be required as we seek to create the same type of effective safety training in medicine that has been present in other high-risk professions.

Competency-based education in anesthesiology: history and challenges.

The Accreditation Council for Graduate Medical Education is transitioning to a competency-based system with milestones to measure progress and define success of residents. The confines of the time-based residency will be relaxed. Curriculum must be redesigned and assessments will need to be precise and in-depth. Core anesthesiology faculty will be identified and will be the "trained observers" of the residents' progress. There will be logistic challenges requiring creative management by program directors. There may be residents who achieve "expert" status earlier than the required 36 months of clinical anesthesia education, whereas others may struggle to achieve acceptable status and will require additional education time. Faculty must accept both extremes without judgment. Innovative new educational opportunities will need to be created for fast learners. Finally, it will be important that residents embrace this change. This will require programs to clearly define the specific aims and measurement endpoints for advancement and success.